GLASGOW, SCOTLAND – Upper-limb dysfunction in early rheumatoid arthritis patients can be significantly improved by a combined exercise and education strategy compared with usual care, based on preliminary findings of an assessor-blinded, randomized controlled trial.
Disability, function, hand grip strength, and self-efficacy assessed using the patient-rated Arthritis Self-Efficacy Scale (Arthritis Rheum. 1989;32:37-44) were all significantly (P less than .05) improved at 3 months in the EXTRA (Education and Exercise Upper-Limb Training in Early Rheumatoid Arthritis) study
"Whilst self-efficacy improved throughout the study, the [effects of the] other outcome measures did diminish, [and] efficacy was not sustained at 9 months," according to chief investigator for the trial Dr. Lindsay Bearne.
"However, the program is safe in people with early RA with moderate to high disease activity," Dr. Bearne, a lecturer in physiotherapy at King’s College London, added at the annual meeting of the British Society for Rheumatology.
The management approach being tested in the EXTRA study differs from other trials of exercise in RA in that it specifically addresses upper-limb dysfunction. The few previous trials that have been done focused on the effects of whole-body or lower-limb exercise or assessed only disability in the hand and wrist.
The aim of the EXTRA study, therefore, was to specifically look at the combined 12-week efficacy of a home-based exercise regimen supplemented with four group discussion and exercise sessions, versus usual care, for upper-limb rehabilitation in patients with early RA.
The primary hypothesis was that greater upper-limb function and less disability would be achieved with the exercise and education program than with usual care.
A total of 108 adults (82 women) with an average age of 55 years participated. All had early RA, with an average disease duration of 20 months. Patients who had received steroid injections in the previous 4 weeks or who had upper-limb surgery or physiotherapy in the past 6 months had been excluded.
The primary efficacy measure was improvement in upper-limb dysfunction assessed via the Disability of Arm, Shoulder, and Hand (DASH) outcome questionnaire. This is a 30-item disability/symptom scale with which patients rate their responses on a 5-point scale. An overall score from 0 (no disability) to 100 is obtained (BMC Musculoskeletal Disord. 2003;4:11).
Secondary assessments included hand-grip strength, self-efficacy, and a grip ability test for function. The 28-joint disease activity score (DAS28) was also used, and pain was assessed using a visual analog scale.
The daily home exercise program used in the study involved six simple exercises selected to suit the patient from an overall list of 16 exercises. The main "menu" of exercises selected to improve upper-limb strength and function was based on expert opinion and the published literature, Dr. Bearne explained, and included arm curls and squeezing a ball of putty.
DAS28 and pain scores at 3 months were both significantly lower (P less than .05) in the patients who had been randomized to the EXTRA program versus the usual care group. DAS28 and pain scores at baseline and at 9 months’ follow-up were not significantly different between the groups.
These data highlight that personalized, well-described global upper-limb exercises and a self-management program can help improve upper-limb dysfunction, if only temporarily.
"The challenge of sustaining long-term exercise remains," said Dr. Bearne.
"We appear to be able to motivate people to exercise, and to initiate exercise; [the difficulty is] to take that initial burst of enthusiasm and convert it to a longer-term habit."
Further data, including the results of a health economic evaluation, are expected from the EXTRA study.
Dr. Bearne reported no relevant financial disclosures. EXTRA is funded by the Chartered Society of Physiotherapy/Physiotherapy Research Foundation and sponsored by King’s College London.